In summer 2015, news that New York model Lauren Wasser had lost a leg to toxic shock syndrome (TSS) at age 24 sent swarms of women on a quest to find safer alternatives to tampons. The moment echoed one from the early 1980s, when nearly 900 cases of year of toxic shock were linked to a then little-known disease called toxic shock syndrome and one super-absorbent brand of tampon was pulled off the market.

If you haven’t heard of it, toxic shock syndrome is a rare but dangerous and potentially deadly bacterial infection. You can get TSS following burns, skin infections and surgery, but at least half the cases are linked to tampon use during menstruation.

As the federal women’s health agency women.gov warns, “Using tampons that are too absorbent or not changing them often enough can put you at risk of toxic shock syndrome.” Why? The fiber in the tampon can serve as a breeding ground for staph bacteria (Staphyloccocus aureas) in women who carry the bugs in their body and haven't developed immunity to them (most have).

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“These history lessons bear repeating”

Women have a much, much lower risk of getting TSS today than several decades ago — but they should still be alert to the possibility, according to Holly S. Puritz, MD, FACOG, chair of the Virginia chapter of the American Congress of Obstetricians and Gynecologists. Over her 30 years in private practice, she’s seen how research and education helped slash death and illness from TSS after researchers linked it to tampon use. As doctors learned how to recognize toxic shock syndrome and women to better protect themselves from it, tampon-linked cases of TSS dropped from 890 a year in 1980 to between 3 and 50 a year today.

“It really is a public health success story,” says Puritz, who says early detection is key and that doctors now know to look for TSS if a young woman who is menstruating comes in with a sudden fever.

The incidence is so low, in fact, that a representative of the Centers for Disease Control and Prevention told SafeBee the agency no longer updates its information on TSS. A doctor in San Francisco said her hospital’s emergency room had not seen a case of tampon-related TSS in more than 30 years. Another felt that even writing about TSS might alarm young women unduly.

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But even if there are just a handful of cases each year, you don’t want to be one of them, Puritz contends. “These history lessons bear repeating every decade because we still see plenty of young women who come in the clinic for a bad-smelling discharge, and we find a tampon that they’ve forgotten about still in place,” she says. “We now know how to advise girls to best use tampons.”

Here are tips on how to avoid tampon-related TSS, according to women.gov and the Food and Drug Administration:

  • Follow the package instructions for insertion.
  • Choose the lowest absorbency for your flow.
  • Change your tampon at least every 4 to 8 hours (some gynecologists recommend changing your it every 2 to 3 hours to be on the safe side).
  • Consider alternating between pads and tampons.
  • Know the warning signs of TSS (below).
  • Don't use tampons between periods.
  • Use pads if you have a cut or scratch in your vagina (it may be safer to use pads after sex for that reason).

Many gynecologists also recommend never leaving a tampon in overnight, and at least one tampon manufacturer recommends that if you tend to sleep more than 8 hours, use pads at night instead.

Scientists disagree over whether synthetic fiber tampons increase the risk of TSS — studies are not conclusive — but at least one prominent researcher insists that all-cotton tampons are far safer than ones made with synthetic fiber. Philip Tierno, Jr., PhD, a professor of microbiology and pathology at the New York University School of Medicine, has told reporters that synthetic fiber tampons provide an environment conductive to bacterial growth, and that “100 percent cotton tampons provide the lowest risk, if any risk at all.”

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Symptoms of toxic shock syndrome

If you experience any of the symptoms of TSS while using a tampon, you should take out the tampon and get in touch with your doctor immediately, according to women.gov. Symptoms include:

  • sudden fever (over 102 degrees F)
  • a sunburn-like rash
  • muscle aches
  • diarrhea
  • dizziness
  • vomiting or diarrhea
  • sore throat
  • bloodshot eyes
  • confusion
  • low blood pressure (perhaps marked by fainting or a feeling of lightheadedness)

Kathryn Olney is a freelance writer and editor who has served as a reporter and editor for California, San Francisco and Mother Jones magazines.